Knowledge, Attitude and Factors associated with Self-efficacy in Screening and Treatment of Hepatitis C among Primary Care Doctors in Selangor

Abstract Introduction: Primary care doctors (PCDs) play an increasingly important role in the management of hepatitis C. It is essential for PCDs to have good self-efficacy in screening and treating hepatitis C to achieve good outcomes. This study aimed to determine the knowledge and attitude towards and other factors associated with self-efficacy in screening and treating hepatitis C. Methods: This cross-sectional study was conducted using an online Google Form. PCDs working at primary healthcare clinics were selected via simple random sampling. The online form contained items on sociodemographic and practice characteristics and a validated questionnaire on knowledge, attitude and self-efficacy towards screening and treating hepatitis C. Data were statistically analysed. Results: A total of 242 PCDs were included in the analysis. The median age was 35 years (interquartile range [IQR]=5). The majority of the PCDs were women (83.9%) and Malay (71.9%) and had a median working experience of 6 years (IQR=6). The mean self-efficacy score was 12.67 (standard deviation=3.38). The factors associated with a higher level of self-efficacy in screening and treating hepatitis C were postgraduate qualification, training within the last one year, better knowledge and attitude scores and prior experience in treating hepatitis C. Conclusion: The identified factors are crucial in improving the self-efficacy among PCDs in hepatitis C care services. Policymakers are suggested to implement training programmes and encourage continuous medical education, exposure to patient management and postgraduate certification in family medicine to help PCDs in treating hepatitis C better.


Introduction
In 2022, the Ministry of Health (MoH) Malaysia announced an increase in the availability of point-of-care diagnostic kits and treatment for hepatitis C (hep C) at public primary healthcare clinics. 1 is pledge sought to improve access to screening, diagnosis and treatment by incorporating hep C management at primary healthcare clinics.It followed a series of initiatives by the MoH to combat the rise in the prevalence of hep C, with 2.5% of patients currently living with the virus and many more who are unaware of their hep C status, 2 and the increase in the numbers of death due to hep C. 3 In 2019, the MoH launched the clinical practice guidelines in the management of hep C. 4 In 2021, the MoH announced the aim for Malaysia to become a hep C treatment hub in o ering the latest antiviral treatment in response to the WHO's mission to reduce new hep C infection by 90%. 5 e latest antiviral treatment, known as directacting antivirals (DAAs), was introduced in 2013.DAAs are more e ective, well tolerated and given for 12-24 weeks compared with older injectable interferons that are di cult to administer and associated with severe adverse e ects. 6Treatment must be initiated among patients with hep C since it can reduce the risk of developing hepatocellular carcinoma. 7 diagnostic kit mentioned above is simple and useful in screening hep C virus (HCV).It is a point-of-care serological and nucleic acid test for HCV. 8 Despite the subsidy and availability of treatment, making hep C essentially curable, the disease remains a public health concern, as the majority of people living with hep C are unaware of their diagnosis, and the disease is usually diagnosed at a later stage with manifestations of liver cirrhosis or hepatocellular carcinoma.9,10 Studies show that screening and treating hep C in primary healthcare settings are feasible and as e ective as managing the disease in hospital settings.11 e inclusion of primary healthcare clinics as the rst point of contact for screening and treating hep C plays a major role in the success of this programme.erefore, the ability and con dence of primary care doctors (PCDs) in ful lling this task require further scrutiny.e self-e cacy theory states that it is individuals' particular set of self-belief or selfcon dence that determines how well they can execute a plan of action in a prospective situation.12 erefore, according to this theory, a higher level of self-e cacy in screening and treating hep C among PCDs will lead to better patient care.
is study aimed to determine the knowledge and attitude towards and other factors associated with self-e cacy in hep C screening and treatment among PCDs.
e ndings of this study are expected to complement the MoH's vision to improve patient care for hep C.

Study design and population
is cross-sectional study was conducted among PCDs working at public healthcare clinics within the state of Selangor using a self-administered online questionnaire.PCDs comprised family medicine specialists (FMSs) and medical o cers.PCDs who were practising at public healthcare clinics in Selangor, were registered with the Malaysian Medical Council and had more than 6 months of experience working at the primary healthcare clinics were included.PCDs who were on long leave of more than 6 months were excluded.Data were collected from June to September 2022.

Sample size calculation
e sample size was calculated using G*Power version 3.1 for multiple linear regression (MLR) and as previously described by Richmond et al.13With an α value of 0.05, a power of 95%, an R 2 value for hep C knowledge among medical practitioners of 0.32 and an R 2 value for attitude towards hep C of 0.30, the estimated sample size was 116.Given an attrition rate of 64% for online questionnaires, the link to the questionnaire was distributed to at least 320 PCDs.

Sampling method and data collection
e PCDs were selected via simple random sampling.
ere are a total of 79 public healthcare clinics in Selangor, and an updated list of all PCDs working at these clinics was obtained from the district health o ces in the state.Simple random sampling was applied to this list using an online random number generator, and the selected PCDs were invited to participate in the study with the help of the FMS in charge of the clinic.e participants were given a link to the online Google Form, which included information regarding the study.Consent was obtained within the online form prior to proceeding to the questions.Reminders were sent 2-4 weeks after the initial invitation.

Study instrument and validation
e self-administered online questionnaire consisted of items on sociodemographic and practice characteristics as well as knowledge, attitude and self-e cacy towards hep C screening and treatment.
e questionnaire was originally designed by Doshi et al. in a United States study, and their ndings were published in a peer-reviewed journal. 14 questionnaire was developed in English and contains items covering knowledge, attitude and self-rated pro ciency (self-e cacy) towards hep C screening and treatment.In this study, it was retained in the original language and unchanged.Permission to use the questionnaire was obtained from the developers.e sociodemographic and practice characteristics included the participants' age, sex, ethnicity, educational level, location of practice, type of practice, duration of practice, number of patients seen in an average day, availability of referral services, prior hep C education and estimated number of patients screened, diagnosed and treated for hep C. e knowledge domain of the questionnaire consists of seven items with pre-determined correct answers.
e rst item is a standalone question on screening indications.e other six items measure knowledge of hep C screening and treatment and are scored with a minimum sum of 0 and a maximum sum of 6. e attitude domain has 10 items and is scored using a 5-point Likert scale.e score ranges from 1 (strongly disagree) to 5 (strongly agree) for positive statements, while the scoring reverses for negative statements with a maximum score of 50.e self-e cacy domain is scored using a 5-point Likert scale based on ve items on aspects of hep C care with a maximum score of 25.For all domains, a higher score represents better knowledge, attitude and self-e cacy.
Content validation, face validation and a pilot study were performed to ensure that the questionnaire was reliable and valid to be used among the Malaysian PCDs.For content validation, a content validation index (CVI) forms were used among six experts from gastroenterology, infectious disease and family medicine, and the calculated S-CVI/Ave for the questionnaire was 0.93.For face validation, the S-CVI/Ave was 0.95.
e questionnaire was then pilot-tested on 30 PCDs who were not included in the main study.e Cronbach's α values for the knowledge, attitude and self-e cacy domains were 0.77, 0.76 and 0.89, respectively.e Cronbach α value for the entire questionnaire was 0.82, indicating that the questionnaire had good internal consistency and reliability.

Data analysis
e data collected were analysed using SPSS version 28 (IBM, Chicago, IL, USA).e sociodemographic and practice characteristics were evaluated using descriptive statistics.Normally distributed continuous data were presented as means ± standard deviations and non-normally distributed data as medians and interquartile ranges (IQRs).Conversely, categorical data were described as frequencies and percentages.e total mean scores were calculated for the knowledge, attitude and selfe cacy domains.
e relationship between the independent variables (sociodemographic and practice characteristics, knowledge and attitude) and the dependent variable (selfe cacy) was determined using simple linear regression.All independent variables with a P-value of <0.25 were included in the MLR using the stepwise method.Statistical signi cance was considered at a P-value of <0.05.Any signi cant variables in the MLR were checked for interaction and multicollinearity.
e model was then tested for homoscedasticity to evaluate the model tness.e model was also checked for linearity by generating scatter plots between residuals and predicted values.

Results
A total of 320 PCDs were invited to participate in this study, among whom 255 agreed, yielding a response rate of 80%.
irteen PCDs were excluded, as they did not ful l the inclusion criteria.us, a total of 242 participants were included in the nal analysis.e knowledge score is presented as medians (IQRs) and the attitude and self-e cacy scores as means (SDs).
Table 3 presents the ndings of the univariate analysis using simple linear regression.e factors with a P-value of <0.25 in this analysis were included in the MLR analysis.e rst factor identi ed was postgraduate quali cation.PCDs with postgraduate quali cation tend to be more con dent in their ability to treat hep C.
is could be attributed to them receiving training or having the opportunity to manage patients with hep C in hospitals or during their attachment in primary healthcare clinics.Studies have shown that in general, primary care trainees are more con dent about their skills, and there are improvements in knowledge following a vocational training programme. 15As part of the healthcare transformation plan, the MoH plans to increase the number of FMSs in Malaysia.e aim is to have about 8000 FMSs to be placed in healthcare clinics nationwide. 16urrently, in Malaysia, doctors are not required to undergo postgraduate training following a basic medical degree to practise in a primary care setting.e ndings of this study support the need to introduce family medicine postgraduate certi cation as a requirement for entry into the eld of family medicine.Strategies should be implemented to encourage PCDs to pursue postgraduate study and become specialists.is will contribute to the production of competent and skilled doctors to cater to the current health needs including the management of hep C.
In the present study, better self-e cacy in hep C management was noted in the PCDs who received prior training or education in hep C management within the past 1 year.Such training can be in the form of seminars, continuing medical education (CME) or courses.Training and CME are necessary for PCDs to stay updated with new DAAs and strengthen their knowledge in managing hep C e ectively. 17is study also found that a small increase in the knowledge and attitude scores increased the self-e cacy score. is nding is consistent with the self-e cacy theory, wherein knowledge and attitude are contributors to performance accomplishment.With more knowledge and better attitude, individuals are more likely to feel able to accomplish a speci c task. 18Insu cient knowledge among PCDs is one of the barriers to scaling up hep C treatment at primary healthcare clinics in Malaysia. 19PCDs' knowledge, belief and feel towards hep C play an important role in hep C care provision. 13It is proven that educational intervention and training improve knowledge and attitude. 20e Malaysian clinical practice guidelines in hep C management should be made accessible to all PCDs, and echo training can be conducted to improve knowledge, attitude and self-e cacy.
Herein, the descriptive analysis revealed that the PCDs were good at identifying patients at a high risk for hep C, such as those with HIV infection and IV drug users.However, they were less aware of the risk among patients who had blood transfusion prior to 1994.A targeted training can improve the knowledge and attitude towards hep C and self-e cacy to identify patients at risk, conduct point-of-care testing, initiate DAA treatment and perform necessary referrals to hospitals. 20Enhancing hep C training and using e ective teaching methods tailored towards PCDs can improve knowledge and attitude, leading to better selfe cacy and hep C outcomes. 20It is known that improving PCDs' capacity to screen and treat will be most impactful if the focus is on training those who are exposed to patients with HCV and who have an existing supportive system. 21nally, the PCDs with prior experience in managing hep C showed a higher level of self-e cacy in this study.
is nding is supported by the self-e cacy theory in that past experience is the most crucial source of self-e cacy. 12People are more likely to feel competent and perform a task well if they have previously completed a similar task. 12Hep C testing and treatment within primary healthcare settings in Malaysia were introduced in 2018, 9 providing a wide range of hep C care services, including the initiation of DAAs, while hospitals focused on treating patients with complications such as cirrhosis and treatment failure. 19Despite this, there are PCDs still lacking experience in managing hep C, which is associated with the lack of knowledge and con dence in managing such. 19ot all PCDs are placed in hep C clinics, and only some will have the opportunity to manage patients with hep C. It is important for rota-makers to ensure that PCDs have the opportunity and exposure to manage hep C when they are attached at primary healthcare clinics.
is is because PCDs' capacity in screening and treating hep C is most impactful among those who have handled large numbers of hep C cases and received good training. 14,21ve factors identi ed in the study are important in improving the self-e cacy among PCDs in hep C care services.Policymakers are suggested to implement training programmes and encourage CME, exposure to patient management and postgraduate certi cation in family medicine to help PCDs in treating hep C better in Malaysia.
To the authors' knowledge, this study is the rst local study to evaluate the knowledge and attitude towards and other factors associated with self-e cacy in hep C screening and treatment among PCDs.
e ndings could guide policymakers in implementing measures to improve PCDs' self-e cacy in managing hep C. Nonetheless, there are limitations that should be considered.One limitation is that the data were collected only in one state (Selangor) and may therefore not represent the entire country.Another limitation is the use

Table 2
shows the median knowledge, mean attitude and mean self-e cacy scores for hep C screening and treatment.A score of 5/6 for knowledge was considered high; a score of 38.11/50 for attitude was considered fairly high; and a score of 12.67/25 for self-e cacy was considered average.

Table 2 .
Knowledge, attitude and self-e cacy scores for hepatitis C screening and treatment.

Table 3 .
Simple linear regression analysis of the factors associated with self-e cacy.

Table 4
shows the factors associated with the self-e cacy of the PCDs in hep C screening and treatment.In the MLR analysis, ve factors were signi cantly associated with the self-e cacy score, explaining 37% of the variation (R2=0.37).

Table 4 .
Multiple linear regression analysis of the factors associated with self-e cacy in hepatitis C screening and treatment.